Proc. roy. Soc. Med. Volume 70 July 1977
Section of the History of Medicine President F F Cartwright FFARCS
Meeting 2 March 1977
Paper Larrey - What Manner of Man? by R G Richardson MA BM (Shortlands, Kent)1 Dominique Jean Larrey (Fig 1) was undeniably one of the greatest of military surgeons. Yet his character and achievements have never really been appreciated on this side of the Channel. Most people, if they have heard of Larrey at all, would say he was Napoleon's surgeon and, if pressed further, might recall that he invented something called the flying ambulance (Fig 2) and was surgeon-in-chief of the Grande Armee. But these are only half truths. Larrey was never Napoleon's personal surgeon - this job was held by Alexandre Yvan from 1796 until he deserted his master at the first abdication; Yvan was in any case far more to Napoleon's surgical taste as he held conservative views about amputation and the use of the scalpel generally. Larrey, therefore, had to limit his ambition to becoming a surgeon to the Imperial Household. Unfortunately, as chief surgeon to the Imperial Guard - an army of the elite within an army - he was seen as an uncomfortable threat by those who Fig 1 Dominique Jean Larrey, a painting probably by his sought power and influence at Court. Con- friend, Anne Louis Girodet sequently, his ambition was thwarted over and over again by the devious actions of, in particular, Jean Nicolas Corvisart, physician to His Majesty, and Antoine Dubois and Alexis Boyer, surgeons to the Household. In 1813, however, Larrey's claim could be denied no longer and at this eleventh hour he was appointed to a year-old vacancy among the surgeons to the Imperial Household (Fig 3). As far as his achievements in battle are concerned, Larrey should be remembered not just for inventing a flying ambulance but for establishing and putting into practice the whole principle of 1 Correspondence to: The Old Cottage, 258 Bromley Road, Shortlands, Kent, BR2 OBW
Fig 2 Larrey's two-wheeledflying ambulance
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Fig 3 Larrey and Napoleon, an engraving after a painting by Carl Steuben. (By courtesy of the Wellcome Trustees)
casualty evacuation as we understand it today. His flying ambulance was simply the first link of the superb system he built up, virtually from scratch, of caring for the wounded from the battlefield, through clearing stations to base hospitals (Fig 4). As early as 1797, after watching an ambulance division on manceuvres in Italy, Bonaparte remarked 'Your work is one of the greatest conceptions of our age.' Unfortunately for the French soldier, Napoleon proved reluctant to proceed beyond the compliment. Larrey's problems probably began in Egypt when, as surgeon-in-chief to the Army of the Orient, he chose to remain with the soldiers rather than accompany Bonaparte back to France. Then, when he did return two years later in 1801, he put his wife before his future emperor. I believe Napoleon never truly forgave him; and when the new appointments were made, Pierre FranSois Percy was appointed as surgeon-in-chief to the army, which became the Grande Armee, while Larrey was left as chief surgeon to the Consular Guard, later the Imperial Guard. It could of course be argued that Larrey got the best of the bargain, but so far as the army as a whole was concerned it meant that the Guard derived most benefit from Larrey's genius. However, this is not to imply, as some have done, that
Larrey's excellent system was restricted to the Guard, for, whenever circumstances permitted, he would go out of his way to help the casualties of the line. In fact, Percy was frequently late on campaigns, and on many occasions Larrey was ordered to take complete surgical charge. This happened, for example, on the 1805 campaign leading up to Austerlitz; but at Jena the following year when the Imperial Guard was not committed, Marshal Bessieres, its commander, refused Larrey permission to assist his colleagues (Percy included) on the field of battle. 'The Emperor and all the wounded did not cease calling my name on that brilliant but ghastly day', he wrote to his wife, Charlotte. Without his presence any attempt to deal methodically with the casualties and to evacuate them with any semblance of order fell apart at the seams. Larrey succeeded Percy as surgeon-in-chief of the Grande Armee in February 1812, but on Napoleon's return from Elba Percy, who was by then old and infirm, was re-appointed. An assessment of Larrey's character is difficult to make, since contemporary diaries, memoirs, and other works tell us little. We have to rely mainly on the judgments of Napoleon, first in his will: 'The most virtuous man that I have known' (here Napoleon was using the word 'virtuous' in the Roman Republican sense of courage with honour, valour and integrity - it is really untranslatable today as the concept no longer exists); and secondly in his conversations with Dr Barry O'Meara and Dr Archibald Arnott on St Helena. Napoleon said to O'Meara that: 'Larrey was the most honest man, and the best friend to the soldier that I ever knew. . He tormented the generals, and disturbed them out of their beds at night whenever he wanted accomodations or assistance for the wounded or sick. They were all afraid of him, as they knew he would instantly come and make a complaint to me. He paid court to none of them, and was the implacable enemy of the fournisseurs (army contractors).'
And to Arnott, he said: 'I hold him in the highest esteem. If the army were to raise a monument to the memory of one man it should be to that of Larrey.'
Apart from the words of Napoleon, we have the brief comment of an American doctor, J Mason Warren, who wrote home to his father in 1832: 'I made a very pleasant and instructive visit, a few days since, to the H6tel des Invalides, where I attended Larrey in his wards. He is a short, corpulent man, with a very agreeable face. His hair, which is grey, falls in curls over the straight, ornamented collar of the military coat that he wears during his visits. He was very polite to Dr Pierson . . .' (Fig 5).
Proc. roy. Soc. Med. Volume 70 July 1977
Fig 4 Larrey at the Battle ofEylau, 8 February 1807. (By courtesy of the Director, Ecole d'Application du Service de Sante Militaire et de l'Hopital d'Instruction des Armees du Val-de-Grace, Paris)
However, as Larrey himself was very well aware, he had his failings. John Waller, a British naval surgeon, wrote in the introduction to his translation of Larrey's 'Memoires' (1815): 'On the whole, however, notwithstanding a tolerable proportion of disgusting egotism and vaunting, the book, as a system of military surgery ... is an undoubted acquisition to the medical world'; and Johann Heinrich Kopp, writing about his trip in 1824 to French hospitals, tells us how it had become the fashion under the Bourbons to belittle Larrey's surgical ability, to emphasize his tendency to boast and to exaggerate his past exploits. Larrey deeply regretted those aspects of his character that offended people. When his ship was lying in quarantine in the Toulon roads on his return from Egypt he received news from Charlotte that some so-called friends (of whom Dubois was one) had been spreading malicious gossip about him. He wrote back:
Fig 5 Larrey in about 1832, a lithograph by F S Delpech (By courtesy of the Wellcome Trustees)
'It would give me the greatest pain to incur anyone's hatred. I know that my defects and my extreme selfassurance invite criticism from those who wish me ill; but if they understood my feelings and my generosity they would be aware of my goodwill and my esteem.'
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There is no doubt, however, that he held a very high opinion of himself and expected others to do likewise. Nevertheless, if a man is to be judged by the company he keeps, Larrey ranks very high indeed since he numbered among his closest friends three of Napoleon's finest soldiers: Desaix, killed in the moment of victory at Marengo, and Lannes and Duroc who both died in agony while Larrey could only watch, grief stricken and unable to help. In a way these friendships were surprising, if we remember the social gap that existed (even in the glorious days of the Revolution) between the fighting man and the surgeon. Socially, the status of an army medical officer was low and the conditions of service did nothing to attract the best type of man. Pay was poor and, particularly on active service, irregular; moreover, a medical officer had neither military rank nor authority. Combatant officers, on the other hand, lined their pockets handsomely with the spoils of war and petitioned their sovereign for rewards. In such a situation an idealist could only be his own worst enemy; and Larrey was an idealist. Life in the army medical services of the Consulate and the first Empire was not easy, but for a humane surgeon who would not conform and who believed in the principles of the Revolution it could be crucifying. Larrey found petitioning for the rewards which he maintained were his due, a distasteful practice; and in treating casualties he took the wounded in order of their surgical need regardless of rank or even nationality - a habit that did not meet with the approval of those who considered themselves more equal than the rest. 'To perform a task as difficult as that which is imposed on a military surgeon,' Larrey wrote in his 1813 campaign journal 'I am convinced that one must sacrifice oneself, perhaps entirely, to others; must scorn fortune and maintain an absolute integrity; and must innure oneself to flattery.'
The extent to which he succeeded in his chosen task can be measured by the devotion he inspired among Napoleon's soldiers. However, such emotions were not shared by others. Napoleon, as I have said earlier, remarked that the Administration both hated and feared him - feelings that derived mainly from the incompetence of its staff. Among his professional colleagues jealousy was at the root of his troubles; his brilliance as a surgeon, both diagnostically and operatively, was uncanny; by comparison, his colleagues were ignorant, and they lacked any comprehension of what he was about. Larrey, in his turn, could not understand why they failed to follow his example. Again in his 1813 journal, he wrote:
'I often think that those who cling to conservatism must recognize the need for operation, even though it may call for ingenuity, yet they fail to perform it through fear or some equally futile reason. They are guilty men.'
The 1813 journal also contains soul-searching passages which, I think, bear comparison with Beethoven's Heiligenstadt testament. The passing of time had not mellowed Larrey - it never did and he was still desperately concerned about how he appeared to others. Thus, he wrote: 'I confess I have never had any desire other than that of helping the wounded, no intention other than that of doing right ... I have always been, and doubtless always will be, the victim of my sincerity and openness. Often the Emperor has reproached me for being able to see merit in others yet not in myself... I hate foolishness and politics. The truth, even when others cannot see it, marches always before me; I follow it blindly and am in danger of falling into the abyss if that is where it leads me. 'The misfortunes of others affect me strongly. Serious disasters afflict my soul and plunge me into the deepest grief; I often think I can do something to help, and even attempt to remedy the situation. But such is my nature that I am thrown off balance and reason is no longer in
control.' However, it was because of his 'defects' that he was able not just to survive the horrors of Napoleonic warfare, but to keep fighting injustice, corruption, and incompetence to the day he died. Others swam with the tide or were submerged completely; but Larrey never once allowed his compassion and gentleness towards the sick and wounded to be eroded to the slightest degree - as a military surgeon he stood alone. However, I feel we might be able to make a clearer assessment of Larrey's character if we view him in the light of the Peter principle - this states that 'in a hierarchy, every employee tends to rise to his level of incompetence'. Did Larrey exemplify this principle when he became surgeon-in-chief of the Grande Armee, or was he thwarted by the obstructive tactics of the Administration and a medical staff that was inadequate both in numbers and in innate medical ability? I have already mentioned one event that might be considered to show that the Peter principle is applicable: Napoleon's appointment of Percy as surgeon-in-chief on his return from Elba. Percy was then 61 (Larrey was 49), moreover, he had shown signs of heart trouble in Spain and had not seen active service since 1811. The fact that Percy was a disaster does not affect the argument - he was chosen in preference to Larrey. Larrey retired disgruntled and Napoleon had to send Drouot to persuade him to come back to his old job as surgeon to the Imperial Guard. At Ligny the regiments of the line, who bore the brunt of the battle against Blucher, had no organ-
Proc. roy. Soc. Med. Volume 70 July 1977
ized system of casualty evacuation and when the French moved on the next day, amongst those left behind was Percy, complaining of his heart. For the last time Larrey stepped into the breach but there was little he could do. Moreover, despite the fact that Larrey had conducted the surgical affairs of the Army of the Orient with impeccable skill and efficiency, Napoleon probably believed him unsuited to the top position in view of his seemingly greater concern with the details of operation and dressing than with the broader sweep of administering the surgical services. Once, in the Kremlin, Napoleon had taken Larrey to task for 'wasting time' on surgical details when, as surgeon-in-chief he should have been better employed. But it is difficult to judge how much of this was due to an inability to delegate and how much to the practical impossibility of doing so. However, Larrey's turning up for the battle of Borodino with only himself and two assistants would seem to be a clear example of the Peter principle at work. His feelings when told by Napoleon to make arrangements for the forthcoming major battle scarcely do justice to the occasion; 'I was', he wrote, 'greatly disturbed by the news.' For the best of reasons he had left five ambulance divisions and all the surgeons of the reserve at Smolensk; the one ambulance division he had taken forward had become fully occupied dealing with the casualties after Volontina. Mercifully, before the battle began, he found time to appropriate forty-five regimental surgeons to staff the corps and divisional ambulances (dressing and clearing stations) and an unexpected delay allowed some transport and supplies to catch up. Admittedly, everything had been against him: shortage of staff and equipment from the start of the campaign, a bloody-minded administration, and lines of communication that Napoleon seemed determined to stretch until they broke. However, whatever practical difficulties he faced, no surgeon-in-chief should have got himself into such a position. So was it incompetence or was it inevitability? Again, I would hesitate to judge, although a pointer in Larrey's favour is his per-
formance throughout the 1813 campaign in Saxony culminating with the immaculate evacuation of casualties by road and river after the Battle of Montereau (a mere forty miles from Paris) on January 18, 1814. If forced to take a decision, however, I would say that the Peter principle did, in fact, apply to Larrey. He was a supe'rb chief surgeon to the Imperial Guard where he could hold the entire system, both surgical and administrative, within the palm of his large hand - and the Guard was by no means small; it comprised fifty thousand of the near half million men who crossed the Niemen into Russia. The entire Army of the Orient was, by comparison, about thirty-three thousand strong. But to be surgeon-in-chief of the Grande Armee, a man had to be an administrator first and a surgeon second. And this was something Larrey could never be; for him, the sick and wounded came first whatever the cost. Perhaps if the Administration had not obstructed the medical services and Larrey in particular, things might have been different; for whilst Larrey was fortunate with the Guard where he could exercise both his surgical and his administrative skills side by side, in the Grande Armee he was exposed and at the mercy of the system. However, conflict between medicine and its administrators is a perennial problem; Larrey could find no solution and today we are still searching, and with a desperation just as great. In this context the lesson we have to learn from Larrey is that doctors must never allow the control of their destiny to slip from the hands of those whose primary concern is the care of the sick. BIBLIOGRAPHY Kopp J H (1825) Aerztliche Bemerkungen, veranlasst durch eine Reise in Deutschland und Frankreich im Fruhjahre und Sommer 1824. Hermann, Frankfurt am Main Larrey D J Unpublished collection of letters, papers, his 1813 campaign journal, and other documents in the Wellcome Institute of the History of Medicine, London Peter L J & Hull R (1969) The Peter Principle. Morrow, New York Richardson R G (1974) Larrey: Surgeon to Napoleon's Imperial Guard. Murray, London